UNIVERSITY MEDICAL SERVICES
OCCUPATIONAL HEALTH
RESPIRATORY/SKIN SURVEILLANCE
This questionnaire should be completed by people whose work activity will potentially expose them to
substances that may cause occupational asthma or skin disease. If the individual is found to be fit for
the activity, surveillance should be repeated again at six weeks after the work activity has commenced,
and annually thereafter (unless the university occupational health adviser determines otherwise).
PLEASE COMPLETE AND BRING WITH YOU TO YOUR APPOINTMENT
Personal information:
Surname:
Dept/School:
Forename:
Manager/Supervisor:
Date of Birth:
Role / Job Title:
Height:
Weight:
Research Code:
Previous hazard exposure:
During past employment have you ever worked with any respiratory or skin sensitisers?
If yes please provide details:
Yes
No
Did you suffer any ill effects from working with these substances?
If yes please provide details:
Yes
No
Not
applicable
Present exposure History:
Give details of respiratory/skin sensitisers you will be working with?
Do you have contact with similar chemicals at home or in other employment?
If yes please provide details:
Yes
No
How many hours on average per week will you spend working with these substances?
Have you been supplied with gloves/masks/PPE for use when
working with these substances?
Yes
No
Do you always wear the gloves/masks/PPE provided?
Yes
No
Have you had any problems with your health since starting your current role?
Yes
No
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Current/History Information: If Yes, please give details
Do you have Asthma or Dermatitis?
Yes
No
Yes
No
Yes
No
Yes
No
Do you have recurrent chest infections?
Yes
No
Do you smoke?
Yes
No
Have you ever smoked?
Yes
No
Are you currently taking any
medications?
Yes
No
Do you have any allergies (including
hayfever)?
History or family history of chronic lung
disease/cancer?
Have you ever consulted your doctor
about chest problems?
If Yes to Asthma what inhalers do you
take?
Amount
Amount
How long ago did you stop?
Symptoms:
Have you ever had or are you currently suffering from any of the following? (do not include isolated
colds, sore throats or flu)
Details
Wheezing, shortness of breath or
chest tightness during your normal
Yes
No
working day?
Stuffiness of your nose, nasal catarrh,
Yes
No
itchy nose or bouts of sneezing?
Bouts of coughing?
Yes
No
Skin Rashes or irritations?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Itchy, sore, red or excessive watering
of the eyes?
Do you usually bring up phlegm first
thing in the morning?
When did you first notice these
symptoms?
Are the symptoms worse in particular
places (e.g. dusty environment)?
If you have symptoms, do any of them
improve when away from work?
CONSENT AND DECLARATION
I confirm that the above responses by me are correct. The purpose of this assessment has been fully
explained to me and I have consented to health surveillance regarding my fitness for work in relation to
potential hazardous substances following COSHH guidelines.
I understand that I have a duty to report any possible symptoms of allergic reactions to substances
encountered in my work to my Manager as soon as possible. I understand that Occupational Health will
inform management on my fitness to work with respiratory and/or skin sensitisers.
Signed:
Date:
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